It’s Thursday, April 30th, and in less than 24 hours, Nebraska will be the first state1 to roll out a version of the Medicaid community engagement requirements from the One Big Beautiful Bill Act. Elsewhere, OpenEvidence gets banned from the EU and the UK, Centene, Humana, Waystar, and Option Care Health report earnings, and we’re enjoying some nice long form from Benjamin Schwartz, MD, Ilana Yurkiewicz, MD, and the folks over at Virtue.
The Grand Roundup will be live again on Monday, May 4th at 12p ET/9a PT
12:15pm ET: Eliana Berger, CEO of Joyful Health, on their $17M Series A.
12:35pm ET: Bryan Roberts, Partner at Venrock, on Eli Lilly’s acquisition of Kelonia Therapeutics.
1:05pm ET: Natalie Davis, CEO of United States of Care, on how healthcare is shaping the 2026 midterms election
1:30pm ET: Brian Miller, Medical Doctor and Hoover Institution visiting fellow, on the turnaround in of the North Carolina State Health Plan and his current research on health care policy and financing.
Puts & Takes
When it comes to eligibility for public programs like Social Security, Medicare, or Medicaid, there are, quite reductively, two schools of thought: the first are “universalists” who think that practically everyone should be eligible for the programs and the second are “means testers” who think public programs should be targeted for people who really need them or demonstrate that they deserve them in some way, for instance, by working, volunteering, or being in school.
Public schools are universal. SNAP is means tested. There are some benefits and drawbacks to both approaches, a spectrum of programs that fall somewhere in between with either universal or means-testing qualities.
An argument the universalists make is that when you have a universal program, you don’t need to add too much in the way of bureaucratic machinery on the top of the program to confirm recipients are eligible. The bureaucratic machinery costs money which is better spent on the actual program goals, say the universalists. It’s ultimately an argument about efficiency. The program costs more, because it covers everyone whether they need it or not, but closer to 100% of the spending is on public program.
The basic shape of the means testers counterargument is summed up nicely in this NYT article (gift linked) about free childcare for upper eastsiders:
A major part of the spending offsets for the One Big Beautiful Bill Act are community requirements for the Medicaid expansion population. Today, for the most part, the eligibility for Medicaid is mostly income driven: below a certain line, you’re eligible, above a certain line, you’re not. Starting tomorrow, May 1st, in Nebraska, and everywhere else in 2027, eligibility is contingent on the income threshold plus participation in a “qualifying activity” with some mandatory and option exemptions.
As Medicaid watchers wait for the final guidance from CMS on the community engagement requirements, Nebraska is providing us something of a peek around the corner at how states are going to architect the bureaucratic machinery to administer this extra level of complexity. Some of the qualifying activities and exemptions are pretty legible to state Medicaid agency trying to determine eligibility. Most employees can get a pay stub and upload it, and data brokers like Equifax are able to share the information with the state for a fee.
Other qualifying activities and exemptions aren’t so easy or so legible for a state, and Nebraska has committed to implementing these work requirements without adding additional staff, so they’re going to allow people to self-attest that they are eligible:
Proving employment status will require documentation, but Nebraska officials say they will allow enrollees to self-attest that they volunteer, go to school, or qualify for exemptions, such as for poor health or caring for a disabled parent. “Supporting documentation, such as medical records, will not be required,” Spilinek said.
The list of what Nebraska considers “medically frail” is also quite expansive, and it seems like quite a lot of people are potentially eligible. If past work requirement implementations are any guide, even broad exemptions and self-attestations will still lead to some attrition in the Medicaid population but if CMS allows states to go down this route of broad exemptions and self-attestations, it seems plausible to me that Medicaid enrollment ends up higher than analysts expected when the OBBBA was passed. If that’s the case, the universalists will be displeased because of extra administrative work its created and the means testers will be upset that people who don’t need or, in their view, don’t deserve Medicaid are still getting it, and all of this will have been a debate full of sound and fury, signifying nothing.
Headlines
agilon health Appoints Tim O’Rourke as Chief Executive Officer: Most recently, Tim was President at Health At Home and before that held various leadership roles at MA plans including Humana.
Two headlines about Devoted:
Devoted Health’s 2025 revenue slips in turbulent Medicare Advantage market with some great analysis from Endpoints’ Shelby Livingston who dug into the state insurance filings for the company.
CEO of For-Profit MA Plan Tells CMS “Pay Us Less” in an interview at Medicarians with Arundhati Parmar, Editor in Chief of MedCity News
Per HIStalk, OpenEvidence withdraws from the UK and EU, citing regulatory uncertainty.
A busy week for earnings coverage with Centene, Humana, Waystar,Option Care Health, and Alignment Health will be reporting after market close today.
The HTN Review
What we’re reading over our morning coffee
In Hard Medicine, Ilana Yurkiewicz, MD, interviews Niskanen Center Senior Health Policy Analyst, Lawson Mansell about what we can do to get more doctors to practice in areas where there’s acute shortages.
Early stage healthcare venture capital firm Virtue shared their hypothesis about A New Actuarial Infrastructure Layer Is Emerging:
In The Surgeon’s Record, Benjamin Schwartz, MD critiques CMMI’s CJR-X mandatory model, arguing for “A targeted, voluntary test of reimbursement restoration for independent orthopedic practices — with episode cost and quality tracked through existing registry infrastructure and claims data.”